CQC failings prompt new patient safety review

The Care Quality Commission (CQC), which regulates healthcare and adult social care in England, has been under scrutiny for the way it rates providers, as well as the internal workings of the organisation.

“Trust leaders have said for some time that the regulator needs urgent reform”

Saffron Cordery

Earlier this year a formal review of the organisation began, led by Dr Penelope Dash, chair of North West London Integrated Care Board, at the instruction of the UK Government.

Dr Dash’s preliminary findings were published in July, and the final report was released to the public earlier today, which has confirmed her previous conclusion that the CQC needs reform.

In response to the report, health and social care secretary Wes Streeting has now asked Dr Dash to carry out a more wide-ranging analysis of England’s patient safety organisations including the CQC, the National Guardian’s Office, the Health Services Safety Investigations Body and others.

For her CQC report, Dr Dash heard evidence from hundreds of service providers and workers, as well as staff from the regulator and national representatives of the health and social care sectors.

“Virtually all [CQC staff] have shared with me considerable concerns about the functioning of the organisation, with a high degree of consistency in the comments made,” said Dr Dash in a foreword to the report.

“At the same time, they recognise the need for a strong, credible and effective regulator of health and social care services.”

She said there was an “urgent need for a rapid turnaround” of the CQC, although acknowledged that the regulator had already started this process since the publication of her interim report in the summer.

“I am pleased to see the openness and honesty with which the organisation has begun to address the changes required,” she added.

Dr Dash found issues regarding the CQC’s efficiency, the clarity of its review system and “significant problems” in its internal IT systems which were “hampering” the way it operated.

The report said the number of inspections being carried out in 2023 was less than half that in 2019, falling from 15,800 to 6,700, and that this was leading to outdated ratings being left up, a backlog in new service provider registration and delays in re-inspection following poor reports.

A new IT system, introduced in 2021, was found to be causing problems for both service providers and staff and damaging the ability of the organisation to roll out its Single Assessment Framework (SAF), the CQC’s reformed review criteria.

The report further found that the SAF itself had issues; Dr Dash highlighted a lack of information about the SAF both internally and externally, and that it lacked attention to the “effectiveness of care”, and did not focus enough on outcomes.

As well as this, Dr Dash criticised the SAF for not making any reference to the “efficient and economic delivery” of services.

The report recommended improvements to the IT system and the SAF, including making ratings more clear. As well as this, she recommended that integrated care system (ICS) inspections be paused while improvements are made to the CQC’s processes.

Further, Dr Dash said the CQC must rebuild the “expertise” of inspectors, which she said had been partially lost in a restructure of the organisation in 2023.

Under the restructure, new integrated teams were created for each local area to replace the previous model which was based on sectors.

The change resulted in an “unequal balance” of specialisms on teams and meant that, sometimes, inspectors were having to assess services in which they lacked knowledge or experience, found Dr Dash.

This, she concluded, had led to relationships between the regulator and service providers breaking down and had made the role of the inspector too much of a “generalist” one.

A CQC executive was quoted in the report as calling the restructure “bonkers”.

Dr Dash’s report coincided with the publication of a further review – commissioned by the CQC itself – by Professor Mike Richards.

Professor Richards called for a “fundamental reset” of the organisation, a return to the sector-based team structure, and many other changes to the operation of the CQC.

“Patient safety is the bedrock of a healthy NHS and social care system”

Wes Streeting

In response to the two reviews, CQC chair Ian Dilks welcomed and accepted the findings, stating that the organisation would “address the recommendations with urgency”.

It pledged four key changes.

The first was to appoint three chief inspectors, one each to lead on regulation of hospitals, primary care and adult social care services, and to consider the introduction of a mental health chief inspector.

Secondly, the CQC pledged to simplify its assessment framework, aiming to improve clarity and remove duplication.

The CQC further promised to “stabilise and fix” its systems, including the provider portal and regulatory platform.

Fourthly, the organisation said it would “improve” the experience for providers of registering with the CQC.

As well as these key changes, the CQC said it would carry forward other suggestions contained in Dr Dash’s report.

These included improving the transparency of review scores, pausing CQC reviews on ICSs and to “strengthen arrangements” for expert involvement in reviews.

Secretary of state for health and social care Mr Streeting pledged, after the publication of Dr Dash’s full report, to “overhaul” healthcare regulation and oversight, in general, to make it “more effective and efficient”.

He said: “Patient safety is the bedrock of a healthy NHS and social care system.

“That’s why we are taking steps to reform the CQC, to root out poor performance and ensure patients can have confidence in its ratings once again.

“This government will never turn a blind eye to failure. An overly complex system of healthcare regulation and oversight is no good for patients or providers.”

Mr Streeting has now tasked Dr Dash with conducting further reports into the remits of the CQC, National Guardian’s Office, Healthwatch England, the Health Services Safety Investigations Body, the Patient Safety Commissioner and NHS Resolution.

The reviews will focus on the organisations’ role in ensuring patient safety and quality, rather than their operational effectiveness.

Health leaders, including NHS Providers deputy chief executive Saffron Cordery, have welcomed the recommendations from Dr Dash, and the CQC’s subsequent promises to improve.

Ms Cordery said the restoration of CQC’s credibility would “take a lot of work”, adding: “Trust leaders have said for some time that the regulator needs urgent reform.

“We have highlighted that the CQC must concentrate more on support and improvement.

“Trust leaders are ready and willing to work with the CQC and all other key organisations as they strive to provide high-quality services for patients and in their quest to keep improving and innovating.”